University Hospital Birth Certificates & Vital Records 1350 Walton Way Augusta, GA 30901 Dear Parent (s), Please PRINT all of your responses neatly and accurately in the spaces below. Please enter the name of the month in all date questions. The information you provide, except the CONFIDENTIAL, CONTACT, and SOCIAL SECURITY information, will be shown on the certified copy of your newborn’s Certificate of Live Birth, which is a legal document. The information asked is collected under the authority of Georgia Code 31-10, Department of Human Resources (DHR) Rules 290-1-3, Federal Law as well as any other applicable Georgia Code and DHR Rules. If you have specific questions about completing this worksheet, please ask the hospital birth certificate registration clerk. Information about Vital Records may be found on the internet at www.georgia.gov or by calling the state Office of Vital Records or your local Vital Records office at (706) 667-4334. Forms Must Be Completed In INK Please Mail Or Bring This Worksheet With You To The Hospital Please Sign The Worksheet On Page # 6 INSTRUCTIONS FOR NEW PARENTS: VITAL RECORDS REQUIRES THAT A BIRTH CERTIFICATE BE FILED ON EVERY CHILD WITH IN FIVE DAYS OF THEIR BIRTH. If you are unsure about an answer, Write or check “UNKNOWN” on the worksheet. These forms must be given to University Hospital Personnel at your OB Advisor (Pre- registration) Appointment or to the Birth Certificate Clerks when you are admitted to the hospital to deliver your baby. If the Mother is UNMARRIED, Please read the section under “Fathers Information” concerning paternity Please call with any questions The Birth certificate/Vital Statistic Office is open Monday – Friday 8am to 4pm Thank You, Blanca Corujo Vital Records Health Information Services Third Floor (706) 774-5859 or Extension 45859 Page 1 of 6 11/ 14/ 2010 YOUR BABY’S Information (PLEASE PRINT) ____________________________ _____________________ Baby’s First Name Middle ____________________________ ____________ Last Suffix (JR, II, III) Are you breast-feeding, or partially even breast-feeding your baby? ____ YES ____ NO Social Security Number for This Child If you answer YES to the question below, information will be taken from the Certificate of Live Birth once the birth certificate is registered with the State Office of Vital Records. After the birth data is sent electronically to the SSA you should receive a social security card for this child in the mail. Allow at least 6 to 8 weeks from the child’s date of birth for the social security card to arrive. All questions about social security cards should be directed to the Social Security Administration at 1- 800-772-1213. Even if you select YES below, Georgia Vital Records can not guarantee your child will receive a social security number. An SSN will not be issued for this child if the birth certificate cannot be processed due to missing, incorrect or inaccurate information; wrong address; the child’s name is incomplete; the certificate is received by Vital Records one year after the child’s date of birth; or the SSA does not receive or process the information. Are you requesting a Social Security Number for this child? (circle one) Yes No This section is to be filled out by Hospital Staff: Date of Birth Time of Birth Sex (circle) Name of the Facility/Hospital: ___/___/______ ___: ___ AM/PM Male Female University Hospital (month/day/year) Child’s Weight: ______lbs. Gestation (week’s)____ Apgar score (5 min) ________ If score is less than 6, 10 min score _____ Single Birth_____ Twin A or B______ Triplet A, B, or C_____ Quad A, B, C, or D ______ Page 2 of 6 11/ 14/ 2010 Mother of Child Information (only) ______________________________________________________________________________ Mother’s First Name Mother’s Middle Name Mother’s Last Name _______________________________________ (__ __ __) ___ ___ ___ - ___ ___ ___ ___ Mother’s Last Name at Birth (Maiden Name) Mother’s Home Telephone Number ____________________/ __________/____________ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Mother’s Date of Birth (month name, day, 4-digit year) Mother’s 9 Digit Social Security Number ___________________________ Mother’s State or Country of Birth MOTHER’S RESIDENCE ADDRESS The complete address where you actually live. ___________________________________________________ _______________________________________ Street Number and Name Apt No. City/Town ____________________ _____________ ___________ County Name State or Country Zip Code + 4 INS IDE CITY LIMITS ? __Y es __No __Unknown Number of Y ears_____ Months___ at current residence MOTHER’S MAILING ADDRESS (if different than the residenc e address shown above) _____________________________________________________________________________________________ Street/Apt Number, Street Name/P.O. Box/RR Address City/Town State/Country Zip Code+4 MOTHER’S MARITAL STATUS : This information does not appear on your child’s birth certificate. The information has to be entered into the database to register your baby legally. Giving false information about your marital status can delay registration of your child’s birth certificate and cause legal problems in the future. IS MOTHER MARRIED? _____YES ____ NO If Unmarried, are parents signing a Pat ernit y Ack nowledgment ? _____ Yes _____ No MOTHER’S OCCUP ATION: What do you do for a living? ____________________________ Who do you work for? ______________________ Confidential Information Are you Hi spanic or from Hi spanic origin/descent? ____No, Not Spanish/ Hispanic/Latin ____Yes, Puerto Rican ____Yes, Cuban ____Yes, Other Spanish/ Hispanic/Latino (S pecify )________________ ____Unknown ____Refused MOTHER’S RACE – Pleas e CHECK the race that best describes you: ____ White ____ Black/African American ____Asian Indian ____Chinese ____Filipino ____Japanes e ____Korean ____Vietnamese ____ Native Hawaiian ____Samoan ____Guamanian or Chomorro ____American Indian or Alaska Native (Specify) _______________ ____Other Asian (S pecify) ______________________ ____Other Pacific Islander (S pecify ) ______________ ____Other (S pecify) ___________________________ ____Unknown ____Refused Is there any family member who has been deaf since childhood? ___ Yes ___ No Page 3 of 6 11/ 14/ 2010 Mother of Child Information (continued) MOTHER’S EDUCATION A) Elementary/High School: CIRCLE the highest grade you completed. If foreign education, circle the grade most similar. None 1 2 3 4 5 6 7 8 9 10 11 12 B) CHECK the type of High School diploma you received. ___G.E.D. ___ Diploma ___Did not receive a diploma or G.E.D. C) College/University: A) CIRCLE the number of years of college you have complet ed. If outside the United States, circle the number of years that is most similar. 1 2 3 4 Other number of years: ____ ____Did not attend college D) CHECK the highest degree you have obtained. ___ Associate’s ___ Bachelor’s ___ Master’s ___ Doctorate ____ Did not obtain a degree Questions concerning YOUR PREGNANCY What did you weight before you were pregnant? ______Lbs. ___Unknown What did you weight when you came in to deliver your baby? ______lbs. ___Unk nown How tall are you? ______ Did you get WIC food during this pregnancy? ___Yes ___No Number of previous live births (do not include thi s child) Number now living: _________ None____ Unknown_____ Date of last live birt h ___/ ___/ ______ Number now dead: _________ Number of ot her outcomes (spontaneous or ectopic loss): _______ Date of outcome ___/___/______ Did you receive pre-natal care? ___Yes ___No Date of first prenatal visit: ___/___/______ Date of last prenatal visit: ___/___/______ Total Number of prenat al visits: _______ Principal source of payment for this delivery__________________________(P rivate Insurance or Medicaid) TOBACCO US E During this pregnancy, how many cigarettes did you smoke during an average day? CIRCLE ONE SELECTION None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21+ Page 4 of 6 11/ 14/ 2010 Father of the Child Information (Only) Before completing this section, it is important to understand the following information: If the mother is MARRIED at any time between conception and the birth of the child, Georgia law REQUIRES the husband to be shown as the father of the child, unless a court has previously determined paternity. If the mother is UNMARRIED, the biological father’s name and information can be added to the birth certificate only after a Paternity Acknowledgment (PA) is completed and signed by both parents. It is recommended that a PA be completed while you are in the hospital, but the father must be present to sign the form and have valid photo ID. NOTE: If necessary, a PA may be completed after you leave the hospital at the county Vital Records office or at the State Office of Vital Records. If the mother is not married, the completion of a PA is strongly encouraged to obtain financial support for this child. Information about child support is available from the county Division of Family and Children’s Services office or call (404) 651-9361. ______________________________________________________________________ Father’s First Name Father’s Middle Name Father’s Last Suffix(Jr., I, II) _________________________/ ____/_______________ ___ __ __ - ___ ___ - ___ ___ ___ ___ Father’s Date of Birth (month name, day, 4-digit year) Father’s 9 Digit Social Security Number ___________________________ (______) _______-______________ Father’s State or Country of Birth Father’s Home Telephone Number FATHER’S RESIDENCE ADDRESS __________________________________________________________________________________________ Street Number and Name Apt No. City/Town ____________________ ______________________ ____________ County Name State or Country Zip Code + 4 INSIDE CITY LIMITS? __Yes ___No ___Unknown Number of Years_____ Months___ at current residence FATHER’S OCCUPATION: What do you do for a living? _____________ _______________ Who do you work for? ______________________ Confidential Information Are you Hi spanic or from Hi spanic origin/descent? ____No, Not Spanish/ Hispanic/Latin ____Yes, Puerto Rican ____Yes, Cuban ____Yes, Other Spanish/ Hispanic/Latino (S pecify )________________ ____Unknown ____Refused FATHER’S RACE – Please CHECK the race that best describes you: ____ White ____ Black/African American ____Asian Indian ____Chinese ____Filipino ____Japanes e ____Korean ____Vietnamese ____ Native Hawaiian ____Samoan ____Guamanian or Chomorro ____American Indian or Alaska Native (Specify) _______________ ____Other Asian (S pecify) ______________________ ____Other Pacific Islander (S pecify ) ______________ ____Other (S pecify) ________________________ ___ ____Unknown ____Refused Page 5 of 6 11/ 14/ 2010 Father of the Child Information (continued) FATHER’S EDUCATION E) Elementary/High School: CIRCLE the highest grade you completed. If foreign education, circle the grade most similar. None 1 2 3 4 5 6 7 8 9 10 11 12 F) CHECK the type of High School diploma you received. ___G.E.D. ___ Diploma ___Did not receive a diploma or G.E.D. G) College/University: A) CIRCLE the number of years of college you have completed. If outside the United States, circle the number of years that is most similar. 1 2 3 4 Other number of years: ____ ____Did not attend college H) CHECK the highest degree you have obtained. ___ Associate’s ___ Bachelor’s ___ Master’s ___ Doctorate ____ Did not obtain a degree I have reviewed the information I have entered above and to the best of my knowledge it is accurate and correctly spelled. ____________________________________________________________ ________/ _________ /___________ (Signature of Mother, Father, or Informant) (mont h name, day, 4 digit year) Print Informant’s name if not mother or Father of this child: __________________________________________ First Middle Last Informant’ s relationship to the child: ____________________________________ A Vital Records certified copy of this child’s birth certificate WILL NOT automatically be sent to the mother. The parent(s) must apply for a certified copy of the birth certificate at the Vital Records office located in the county or State where the child was born. The hospital birth certificate registration clerk can furnish the location of the county office. There is a $10.00 fee for the first copy and a $5.00 fee for each additional copy of the same certificate ordered at the same time. Allow at least 6 to 8 weeks before you request a certified copy of this child’s birth certificate. Page 6 of 6 11/ 14/ 2010
"Birth Certificates to Print"